Aims

The Fassier Duval (FD) rod is a third-generation telescopic implant for children with osteogenesis imperfecta (OI). Threaded fixation enables proximal insertion without opening the knee or ankle joint. We have reviewed our combined two-centre experience with this implant.

Aims

Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union.

The aim of this study was to determine whether an osteoplasty of the femoral neck performed at the same time as an intertrochanteric Imhäuser osteotomy led to an improved functional outcome or increased morbidity. A total of 20 hips in 19 patients (12 left, 8 right, 13 male, 6 female), who underwent an Imhäuser intertrochanteric osteotomy following a slipped capital femoral epiphysis were assessed over an eight-year period. A total of 13 hips in 13 patients had an osteoplasty of the femoral neck at the same time. The remaining six patients (seven hips) had intertrochanteric osteotomy alone. The mean age was 15.3 years (13 to 20) with a mean follow-up of 57.8 months (15 to 117); 19 of the slips were severe (Southwick grade III) and one was moderate (grade II), with a mean slip angle of 65.3° (50° to 80°); 17 of the slips were stable and three unstable at initial presentation. The mean Non-Arthritic Hip Scores (NAHS) in patients who underwent osteoplasty was 91.7 (76.3 to 100) and the mean NAHS in patients who did not undergo osteoplasty was 76.6 (41.3 to 100) (p = 0.056). Two patients required a subsequent arthroplasty and neither of these patients had an osteoplasty. No hips developed osteonecrosis or chondrolysis, and there was no increase in complications related to the osteoplasty. We recommend that for patients with a slipped upper femoral epiphysis undergoing an intertrochanteric osteotomy, the addition of an osteoplasty of the femoral neck should be considered.

Cite this article: Bone Joint J 2014;96-B:1119–23.

We report the outcome of 28 patients with spina bifida who between 1989 and 2006 underwent 43 lower extremity deformity corrections using the Ilizarov technique. The indications were a flexion deformity of the knee in 13 limbs, tibial rotational deformity in 11 and foot deformity in 19. The mean age at operation was 12.3 years (5.2 to 20.6). Patients had a mean of 1.6 previous operations (0 to 5) on the affected limb. The mean duration of treatment with a frame was 9.4 weeks (3 to 26) and the mean follow-up was 4.4 years (1 to 9). There were 12 problems (27.9%), five obstacles (11.6%) and 13 complications (30.2%) in the 43 procedures. Further operations were needed in seven patients. Three knees had significant recurrence of deformity. Two tibiae required further surgery for recurrence. All feet were plantigrade and braceable.

We conclude that the Ilizarov technique offers a refreshing approach to the complex lower-limb deformity in spina bifida.

Aim: To compare outcomes in patients who suffered a severe slipped upper femoral epiphysis (SUFE) treated by either a modified Dunn or Imhauser Osteotomy.

Method: A consecutive group of patients were identified retrospectively from the operative records of a single surgeon at two hospitals since 2003. Patient Notes were used to extract age at presentation, duration of symptoms, stability, and time to surgery. Radiographs were examined to determine: the slip angle; and the degree of correction achieved. Patients were assessed using the Harris and Oxford Hip Scores.

Results: Seven patients had a modified Dunn osteotomy and 11 patients an Imhauser osteotomy. Of those only 6 of the Dunn patients and 7 of the Imhauser patients could be recalled for clinical assessment. The average time to clinical assessment from osteotomy was 13.5 months for the Dunn group and 32 months for the Imhauser group. Post-operative lateral radiographs showed a mean angle of deformity correction of 63 degrees in the Dunn and 36 degrees in the Imhauser groups. There were no postoperative complications in either group, specifically no avascular necrosis.

In the Dunn group the Harris Hip Score ranged from 78 to 100, mean 92 (excellent) and the Oxford Hip scores from 12 to 21, mean 17. The Harris Hip Score for the Imhauser group ranged from 50 to 98, mean 76 (fair), and the Oxford scores from 13 to 34, mean 25. Range of motion was similar for both groups in all directions.

Conclusions: The Dunn and Imhauser osteotomies both give good clinical results in the severe SUFE patient. However the Dunn Osteotomy group had better Harris and Oxford Hip Scores, reflecting improved functional outcome.

We compared two management strategies for the perfused but pulseless hand after stabilisation of a Gartland type III supracondylar fracture. We identified 19 patients, of whom 11 were treated conservatively after closed reduction (group 1). Four required secondary exploration, of whom three had median and/or anterior interosseus nerve palsy at presentation. All four were found to have tethering or entrapment of both nerve and vessel at the fracture site. Only two regained patency of the brachial artery, and one patient has a persistent neurological deficit.

In six of the eight patients who were explored early (group 2) the vessel was tethered at the fracture site. In group 2 four patients also had a nerve palsy at presentation and were similarly found to have tethering or entrapment of both the nerve and the vessel. The patency of the brachial artery was restored in all six cases and their neurological deficits recovered completely.

We would recommend early exploration of a Gartland type III supracondylar fracture in patients who present with a coexisting anterior interosseous or median nerve palsy, as these appear to be strongly predictive of nerve and vessel entrapment.

Purpose of study: Septic arthritis and osteomyelitis have traditionally been managed by intravenous antibiotics for 3 to 6 weeks. This requires a prolonged in patient stay, inconvenience to parents, morbidity and cost. A number of authors have suggested that a shortened course of intravenous antibiotics for 7–10 days may be as effective.

This studies reviews the outcomes of a short course regime started in 2001.

Methods: We prospectively reviewed 34 cases of acute osteomyelitis and 28 cases of acute septic arthritis in children. These were confirmed by a positive blood culture or a positive aspirate culture or raised WCC in joint aspirate for septic arthritis; or a positive bone scan/culture for osteomyelitis.

Patients were treated with a 3 day course of intravenous antibiotics, following surgical drainage of joints when required. Providing the clinical and biochemical parameters were improving patients then received 3 weeks oral antibiotics.

The duration of IV administration and of inpatient stay and any incidence of readmission/reoccurrence was noted. Serial measurements of inflammatory markers were recorded.

Results: 35 of the 62 patients received intravenous antibiotics for < 4 days. Mean in-patient stay was 5.5 days. There was one re-admission for recurrence of infection. One patient required a repeat joint washout at 7 days. At 3 months no patients had ongoing infection. There was a correlation between CRP levels and the severity of infection, and therefore the length of treatment required.

Conclusions: We suggest acute suppurative skeletal infection can be managed safely with a shortened course of intravenous and oral antibiotics (following surgical drainage in the case of intra articular infection). Patients must be observed closely by experienced practitioners.

Flexible intramedullary nailing is gaining popularity as an effective method of treating long-bone fractures in children.

We retrospectively reviewed the records and radiographs of 56 unstable fractures of the tibia in 54 children treated between March 1997 and May 2005. All were followed up for at least two months after the removal of the nails.

Of the 56 tibial fractures, 13 were open. There were no nonunions. The mean time to clinical and radiological union was ten weeks. Complications included residual angulation of the tibia, leg-length discrepancy, deep infection and failures of fixation. All achieved an excellent functional outcome.

We conclude that flexible intramedullary fixation is an easy and effective method of management of both open and closed unstable fractures of the tibia in children.

The best method of femoral head containment in Legg-Calvé-Perthes’ disease (LCPD) is still controversial. Triple pelvic osteotomy allows desired rotation of acetabulum, reduces the relative stress, provides optimum femoral head cover and compensates for shortening. The iliac osteotomy was modified to interlock following acetabular rotation to provide extra stability and allow early mobilisation.

Material and methods: We reviewed 21 patients, who underwent interlocking triple pelvic osteotomy for severe Legg-Calvé-Perthes’ disease, to evaluate their clinical, radiological and functional results.

The mean patient age at presentation was 7 years and 7 months. Fourteen hips were in the fragmentation stage whereas 8 were in the early re-ossification stage. Seventeen hips were Herring group C and 5 were group B. Seventeen hips had 2 or more at risk radiological signs. The average period of follow-up was 51 months (range, 33 months to 80 months). The average gain in acetabular head index was 18% and that in centre-edge angle was 22 degrees, more than reported for any other single surgical procedure. According to the Harris hip rating system, there was an average gain of 35 points. Average gains in abduction, internal rotation and flexion were 17, 12 and 28 degrees respectively. The average gain in length of the limb was 6.4 mm.

Interlocking triple pelvic osteotomy in LCPD provides good cover of the femoral head, good symptom relief and markedly improved range of motion. Assessment of a few patients approaching maturity has shown a congruent hip joint with a spherical femoral head.

We have analysed the patterns of management of developmental dysplasia of the hip (DDH) in Coventry over a period of 20 years during which three different screening policies were used.

From 1976 to the end of 1985 we relied on clinical examination alone. The mean surgical cost for the treatment of DDH during this period was £5110 per 1000 live births. This was reduced to £3811 after the introduction of ultrasound for infants with known risk factors. Since June 1989 we have routinely scanned all infants at birth with a mean surgical cost of £468 per 1000 live births. This reduction in cost is a result of the earlier detection of DDH with fewer children requiring surgery. In those who do, fewer and less invasive procedures are needed. The overall rate of treatment has not increased and regular review of patients managed in a Pavlik harness has allowed us to avoid the complication of avascular necrosis.

When we add the cost of running the screening programme to the expense of treating the condition, the overall cost for the management of DDH is comparable for the different screening policies.